Barbara Zielinski, MSW, CCM, does double duty as a case manager and social worker on the women and children's services unit at Ingham Regional Medical Center in Lansing, MI, working with children's protective services or adoption agencies to place some of the infants born at the hospital.

"In other areas of the hospital, the utilization review and discharge planning piece is handled by the RN case managers. On this unit, the patients tend to have so many psychosocial issues that the decision was made to have a social worker coordinate the care of the patients," she says.

The arrangement has been very successful because Zielinski can take care of her patients' psychosocial needs as well as coordinating their care, she points out. "Many of the newborns and/or their mothers have multiple needs. The physicians find it easier to deal with one person rather than a case manager and a social worker," she says.

Zielinski has received training on InterQual criteria for her patient population and utilization review training by the utilization review supervisor. She handles discharge planning for her patients, working with home care agencies and the public health nurse liaison from the country public health department.

"A major part of my work is moving patients through the hospital stay in a timely manner. Coordinating with physicians, nurses, and community agencies is an essential part of my job," Zielinski says.

When she sets up an assessment by children's protective services, an adoption, or a referral to home care, she tries to time the discharge for a time when the patient is stable and the discharge will be safe. "I work to make sure everything is in place so there won't be a delay in the discharge," she says.

Zielinski's patient population includes the birthing center, women with pregnancy problems who have a hospital stay before delivery, pediatric patients, and gynecological medical-surgical patients. She has an average caseload of about 24 patients at a time.

"In the course of a week's time, I see a half-dozen patients who need intensive social work. The bulk of these patients are in the birthing center," she says.

Among these are teenagers who have babies, families with domestic violence issues or unsafe home situations, women at risk for postpartum depression, children or teenagers who have attempted suicide, and women with mental health problems such as schizophrenia, who have delivered babies.

"I receive phone calls from all over our community, such as local foster care agencies or a public health nurse liaison, alerting me to situations where a child may be at risk," Zielinski says.

Accessing patients

Patients who may have psychosocial needs are identified during the nursing staff's thorough assessment of all new patients. The assessment of obstetric and pediatric patients is geared specifically to that patient population. "The nurses are trained to inquire casually about other children to determine if the mother may have lost custody. I get calls from across the community alerting me to situations when a family needs an intervention," Zielinski says.

If Zielinski or the nursing staff are concerned about mother-infant bonding or an unstable home situation, she makes a referral from the hospital for home visits for infant mental health services or family outreach services. The hospital has a protocol to screen both the mothers and the newborns for illicit drugs if they present with certain risk factors.

"We do the screen for the safety of the mother and the baby. If the newborn has been exposed to drugs, we need to know so we can provide medical care," she says.

When a newborn has been exposed to illegal drugs or when the mother of a newborn has had her rights to other children terminated, Zielinski calls in children's protective services to review the situation and determine if it's safe for the baby to go home with the mother.

Last year, she called in children's protective services a total of 79 times out of about 1,800 patients admitted to her units. "I always evaluate the situation to confirm the information we receive. I try to be as nonthreatening as possible. I congratulate the mother on the birth of the baby, check with the nurse to see if the mother and infant are bonding and if the mother is providing appropriate care," she says.

Zielinski asks the mother about the home situation and what kind of preparations have been made for the baby and prepares them for the children's protective services evaluation.

"The mothers are often frightened that their baby will be taken away. I can't give them any assurances but I provide as much support as possible. I explain to the mother that our job as a hospital is to provide the best medical care and that we are required by the law to notify children's protective services but that doesn't change the care she or her baby will receive," she says.

Zielinski encourages the mother to contact a family member or friend for support.

"When children's protective services is going to court to get custody of the infant, it's stressful for the mother. I try to provide as much support as possible but they don't see me as the supportive party," she says.

Nursing staff play support role

The nursing staff also play a supportive role, encouraging the mother to talk with the children's protective services worker.

If there is a court hearing, Zielinski arranges transportation for the mother to make sure she can attend if a family member isn't available to take her.

"If a baby is removed from the mother's care and she comes back to the hospital to say goodbye to her baby, it's an emotionally tense situation. In these cases, a lot of my work is to try to diffuse the emotions," she says.

Zielinski collaborates with adoption agencies and adopting families when women make a decision to place their babies for adoption.

"We are a neutral party and we help the birth mother with whatever plan she decides on. If she changes her mind about the adoption, we assist her in making alternate arrangements," she says.

If she discovers patients who are at high risk for postpartum depression, she recommends a psychiatric consultation and provides resources for ongoing treatment.

"We want the patient to set up an appointment before they leave the hospital," she says.

As they go about teaching during the pregnancy and delivery, the nursing staff notice if the patient exhibits signs and symptoms of postpartum depression, she adds.

"The OB/GYNs are very sensitized to the likelihood of postpartum depression and they screen their patients very carefully," Zielinski says.